Introduction to Psychotherapy

Primer

Psychotherapy (psychological therapy or talking therapy) is the use of psychological methods with regular therapeutic interactions to help an individual change behaviours or overcome symptoms. There are many types of psychotherapies, but at its core the therapist-patient relationship and therapeutic alliance is the most important.[1]

Therapy Efficacy

Debate about which psychotherapy is the “best” has been ongoing since the advent of psychoanalysis. Multiple meta-analyses and comparison studies show that there is no single best psychotherapy (i.e. - there is no gold standard).[2][3][4][5][6] At the end of the day, research has shown that the therapeutic relationship (or therapeutic alliance) matters more than the type of psychotherapy. Good therapeutic alliance occurs when there is a convergence of the patient and therapist on goals, tasks, and overall bond.

Therapist Efficacy

Although all psychotherapies are fundamentally equally effective, the same cannot be said for psychotherapists. Not all therapists are created equal – some therapists are much more effective than other therapists. Ineffective therapists lead to higher dropout rates and greater patient deterioration.[7] Qualities of effective therapists include empathy, the capacity to build and sustain therapeutic alliance, judicious use of interventions, and the ability to attend to and manage countertransference.[8] Mindfulness and resilience are also common factors to an effective therapist.[9] An “unexperienced” therapist who has good interpersonal skills, warmth, empathy, and ability to tolerate conflict and criticism, will do better than an “experienced” therapist who lacks those skills and adheres to a “manualized approach” to therapy.[10]

No matter the type of psychotherapy chosen, psychotherapy should always be thought of as a collaboration (team work!) between the therapist and the patient. Emphasizing a patient's adaptation first and focusing on pathology second is also important. The therapist should also be adaptive and responsive to the patient's culture, coping style, attachment, and reactance.

How To Be An Effective Therapist

  • Develop a strong therapeutic alliance with your patient[11]
  • Have strong interpersonal skills: verbal fluency, warmth, and empathy (in order to have a tailored and in depth understanding of the patient experience)[12]
  • Professional humility and turning self-doubt into a form of reflective practice
  • Be attentive to any pathological beliefs and the maladaptive behaviours during each therapeutic encounter
  • Explore and challenge pathological beliefs, while reinforcing growth through the patient's insight and experience
  • Be open to countertransference and transference, and commenting on this
  • Be attentive to nonverbal cues (tone of voice, body language, gestures, facial expression)
  • Don't forget about process in therapy (the therapeutic relationship between the therapist and the patient)
  • Get feedback from your patient about how they think therapy is going
  • Deliberate practice: invest time learning and refining one's craft in psychotherapy

Therapeutic Alliance

What is therapeutic alliance? Therapeutic alliance is described as “the degree to which the therapy dyad [patient-therapist] is engaged in collaborative, purposive work.”[13] A strong therapeutic alliance can be developed through:

  • Demystifying therapy and educating the patient about how therapy works in general, the duration of therapy, and nature of therapy nature/duration of therapy; early role induction
  • Aligning expectations of treatment, strengthening hope, addressing negative expectations (i.e. - treatment must make sense to the patients!)
  • Being culturally competent
  • Clarifying misunderstandings in a non-defensive and non-blaming fashion
  • Create/provide a new relational experience for patients through the therapist's responsiveness and ongoing therapeutic engagement

Transference and Countertransference

An effective therapist is able to readily identify both transference and countertransference. Transference and countertransference can be positive or negative. Paying special attention to transference and countertransference is especially important in psychodynamic psychotherapy.

  • Transference is the feelings that the patient has toward another person which they unconsciously redirect toward the therapist (e.g. - a patient has feelings of anger towards the therapist, because the therapists reminds the patient of their father, who she despised)
  • Countertransference is when a therapist transfers emotions and feelings towards to a person in therapy, and it is often a reaction to transference (e.g. - a therapist has feelings of goodwill towards a patient with cancer, who reminds them of their mother who recently passed away from cancer)

Access to Care

Psychotherapy has unfortunately been chronically underused and underfunded in most countries, despite evidence of its benefits.[14] This has been exacerbated by many factors, including mental healthcare insurance and funding models that focus on pharmacotherapy, “medication management” clinics, and cultural/academic changes in psychiatry.[15][16][17]

Types

Short-term
Brief (Short-term) Psychodynamic Psychotherapy
Brief (short-term) psychodynamic psychotherapy is a time-limited psychotherapy that focuses on troubling feelings or thoughts that interfere with relationships, communication, and/or functioning.
Cognitive Behavioural Therapy for Insomnia (CBT-I)
Identifies and replace thoughts and behaviors that cause or worsen insomnia with habits that promote improved sleep.
Cognitive Behavioural Therapy (CBT)
Challenges maladaptive thinking patterns and changes emotions/behaviour coming from those thoughts. Indicated in: depression, anxiety, and psychosis.
Cognitive Processing Therapy (CPT)
Challenges and changes unhelpful beliefs related to trauma to create a new conceptualization of traumatic events. Indicated in: PTSD.
Community Reinforcement Approach (CRA)
Uses familial, recreational, occupational, and social events to support a change in substance use behaviours.
Interpersonal Therapy (IPT)
Focuses on relationship conflicts, life-role transitions, and grief. Indicated in: depression.
Variable-term
Dialectical Behavioural Therapy (DBT)
Focuses on acceptance and change, emotional regulation, mindfulness, and distress tolerance. Indicated in: borderline personality and self-harm behaviours.
Family Therapy
Multi-person therapy for when symptoms are exacerbated by interpersonal interactions within the family. Indicated in: disruptive behaviour in children, eating disorders, and schizophrenia.
Group Therapy
One or more therapists work with several individuals simultaneously in a group setting, working through both the process and content of the group.
Motivational Interviewing (MI)
Addresses ambivalence to change using a non-judgmental stance, enhances motivation to change, and acknowledges resistance. Indicated in: substance use disorders.
Supportive Psychotherapy
The therapist is the guide, listens, understands, and reinforces coping skills and adaptive defense mechanisms. Indicated in: lower cognitive function, crisis, schizophrenia
Long-term
Psychodynamic Psychotherapy
Explores unconscious conflicts that cause symptoms and explores past relationships, transference, and defense mechanisms.
Other
Acceptance and Commitment Therapy (ACT)
Uses commitment and behaviour change strategies to increase psychological flexibility.
Biofeedback
A treatment modality where patients use signals from the body (e.g. - heart rate, muscle tension, skin temperature, blood pressure) as a guide.
Eye Movement Desensitization and Reprocessing (EMDR)
Involves the use of a patient's own rhythmic, rapid eye movements.
Mindfulness-Based Therapy
Focusing on and noticing the present as it is using breathing and relaxation techniques.
Trauma-Informed Care
An approach to therapy that takes into account the impacts of trauma in all aspects of a patient's care.

Resources

For Providers

References

1) Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of consulting and clinical psychology, 61(4), 561.
2) Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: as efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174(10), 943-953.
3) Leichsenring, F., & Steinert, C. (2017). Is cognitive behavioral therapy the gold standard for psychotherapy?: The need for plurality in treatment and research. Jama, 318(14), 1323-1324.
4) Barth, J., Munder, T., Gerger, H., Nüesch, E., Trelle, S., Znoj, H., Jüni, P., & Cuijpers, P. (2013). Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis. PLoS medicine, 10(5)
5) Driessen, E., Van, H. L., Don, F. J., Peen, J., Kool, S., Westra, D., ... & Dekker, J. J. (2013). The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: a randomized clinical trial. American Journal of Psychiatry, 170(9), 1041-1050.
6) Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277.
7) Saxon, D., Firth, N., & Barkham, M. (2017). This is especially true for patients with the greatest symptom severity. The relationship between therapist effects and therapy delivery factors: Therapy modality, dosage, and non-completion. Administration and Policy in Mental Health and Mental Health Services Research, 44(5), 705-715.
8) Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48(1), 98.
9) Pereira, J. A., Barkham, M., Kellett, S., & Saxon, D. (2017). The role of practitioner resilience and mindfulness in effective practice: A practice-based feasibility study. Administration and Policy in Mental Health and Mental Health Services Research, 44(5), 691-704.
10) Schöttke, H., Flückiger, C., Goldberg, S. B., Eversmann, J., & Lange, J. (2017). Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol. Psychotherapy Research, 27(6), 642-652.
11) Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277.
12) Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399.
13) Hatcher, R. L., & Barends, A. W. (2006). How a return to theory could help alliance research. Psychotherapy: Theory, research, practice, training, 43(3), 292.
14) Weissman, M. M. (2013). Psychotherapy: a paradox. American Journal of Psychiatry, 170(7), 712-715.
15) Weissman, M. M. (2013). Psychotherapy: a paradox. American Journal of Psychiatry, 170(7), 712-715.
16) Olfson, M., & Marcus, S. C. (2009). National patterns in antidepressant medication treatment. Archives of general psychiatry, 66(8), 848-856.
17) Torrey, W. C., Griesemer, I., & Carpenter-Song, E. A. (2017). Beyond “Med Management”.